MSK conditions :howell

Question 1

Juvenile idiopathic arthritis definition

Answer 1

chronic,systemic inflammatory condition that begins before age 16

begins in at least one joint for at least 6 weeks

on exam, defined as joint swelling or a combination of limited range of motion with pain in a joint

Question 2

JIA incidence

(peak incidences)

Answer 2

more common in women (2:1)

2 peak incidence:
1. 1-3 years old
2. 8-12 years old

Question 3

JIA 3 course patterns

Answer 3

highly variable

monophasic: active systemic, gone after 4-6 months with no recurrence

polycyclic: long periods of inactivity with active episodes (least common)

persistent (Chronic): variable forms (systemic sx wit no srthritis, both systemic and arthris sx, arthritis no systemic sx) most common

Question 4

JIA labs

Answer 4

ESR:
systemic and polyarticular= increased
pauciarticular = normal

anemia= in chronic JIA

high WBC( as white cells entry sybovium they can cause decrease in serum especially in active dz)

(-) RF

ANA: in 33% of children with ocular complications in pauciarticular

Question 5

JIA evaluation

Answer 5

soft tissue swelling
periarticular osteopenia
joint destruction (less frequent in children) erosions and cysts

Question 6

JIA management

Answer 6

eye exams/ophto referral: every 3 months
(+) ANA in 33% of pauciarticular JRA out of this, 10% have chronic uveitis

(-) ANA monitor every 6 months: chance of developing chronic uvitis is diminished each year ANA(-)

at 5 years post-diagnosis monitoring is no longer cost effective

Question 7

JIA complications

Answer 7

blindness: most serious for pauciarticular
joint deforminity: more common in polyarticular JRA
intermittent infections and potentially fatal amyloidosis for protractes systemic JRA
mortality overall is 2%

Question 8

types of JIA , incidence and when is it determined

Answer 8

determined the first 6 months based on sx’s

systemic aka “still’s disease” (20%) , younger childen

Pauciarticular/oligoarticular (50%) most common

polyarticular (30%)

Question 9

Systemic JRA aka still’s disease
diagnostic criteria

Answer 9

diagnostic criteria: fever at least 2 weeks in duration and quotidian= daily intervals where it spikes several times throught the day
must also have one of the following:

typical rash: linear pattern, salmon color, maculopapular, worse with fever and evenings , elicited by scratching (koebner’s phenomenon)

LAO,HSM

or serositis (pericarditis, pleuritis)

Question 10

Systemic juvenile idiopathic arthirtis sx

Answer 10

systemic sx more pronounced than articular sx (within first 6 months)
maybe one joint with mild inflammation

Question 11

Systemic juvenile idiopathic arthirtis labs

Answer 11

mild anemia
elevated: ESR,CRP
Negative: ANA and RF

infectious workout: blood cultures, urine, joint tapping all negative

malignancy workup

Question 12

Pauciarticular/oligoarticular JRA onset and prognosis

Answer 12

onset:2-3 yrs old
good prognosis

Question 13

Pauciarticular/oligoarticular JRA sx

Answer 13

swelling, pain, and stiffness in 2-4 joints

larger joints: knees (very common), elbows, ankles : limping when walking

systemic sx minimal: spiking fevers are not common

eye involvement: higher risk than other JRA
chronic iriidocyclitis manifestation of anterior uveitis
risk of perm vision loss

leg length discrepency of affected leg
before pubertery: leg longer due to synovial thickening
after: leg shorter bc hrowth pltes stop sooner

Question 14

pauciarticular/oligoarticular subgroups

Answer 14

persistent: no additional joint involvement after the first 6 months

extended: involvement of additional joints after first 6 months

Question 15

Polyarticular JRA sx

Answer 15

more likely to persist to adulthood
5 or more joints involved: swelling, pain and stiffness

resembles adult RA: symmetric pattern

C-spine involvement common: decreased ROM and pain in the neck

may have systemic features but less severe than systemic JRA

micrognathia: early closure of ossification centers of the mandible, marked receding of chin, characteristic of polyarticular jra

Question 16

HSP(Henoch-schonlein purpura definition and peak age

Answer 16

a vasculitic syndrome
inflmmation of small blood vessels

peak age: 4-7 years old

Question 17

HSP triad

Answer 17

purpura
colicky(abd pain, cramping that comes and goes)
migratory arthritis

Question 18

HSP complications

Answer 18

renal disease: hematuria/proteinuria

rare condition but urine analysis is needed to rule this out

Question 19

Rheumatic fever etiology

Answer 19

multisystemic inflammatory disease after strep throat group a strep, B hemolytic step pyogenes

Question 20

rheumatic fever incidence

Answer 20

ages 5-15 y/o for first attack
possible relapses later

Question 21

rheumatic fever rash

Answer 21

erythema marginatum

serpiginous rash
evanescent: worse w/fever
well demarcated spreading to trunk and proximal extremeties
not specific
lasts a day or so

Question 22

jones criteria major and minor

Answer 22

one major and 2 minor or 2 major and evidence of strep pharyngitis

Major criteria:
migratory polyarthritis (70%)
carditis (40-50%)
chorea (Syndenhams)
erythema marginatum
subcutaneous nodules: extensor surfaces on

minor:
(+) thorat culture or rising ASO titer
fever
arthalgia
increased acute phase reactant
CRP and ESR elevated
Prolonged PR interval on EKG

Question 23

Evaluation of rheumatic fever

Answer 23

throat culture
ASO titer
chest x-ray
echo
note: valvular defects and mitral valve leaflet prolapse may show up later in life

Question 24

Rheumatoid arthritis etiology

Answer 24

unknown. perhaps autoimmune or infectious agent

Question 25

Rheumatoid arthritis incidence

Answer 25

peak ages: 35-45 years old

prevalence increases with age
3x more common in females
genetics: association with HLA DR4 “dang RA”

twin to twin concordance:15-20%

Question 26

rheumatoid arthitis onset types

Answer 26

70% insidious in onset
20% subacute
10 % explosive or acute

Question 27

RA inflammation process

Answer 27

edema leads to neovascularization
synovial linig thickers (hyperplasia)
erosion occurs at the joint margins
inflmmation leads to seroous effusion
effucion stretches the joint capsule
the joint becomes unstable
deformities form

Question 28

RA sx

Answer 28

fatigue. malaise, wt loss
symmetrical
small and proximal joints 1st: MCPs, PIPs, wrist, MTPs : larger joints later

better with activity

Question 29

common RA hand deformities

Answer 29

fusiform swelling: 1st sign
PIP swelling (synovitis)
sausage finger or spindle shaped

Boutonniere deforminty: flexion of PIP joints and extension at DIP joint

Swan neck: flexion at MCP joint, extension at PIP, flexion at DIP joint

ulnar deviation of fingers

subluxation of the MCP

Question 30

RA extra-articular manifestations

Answer 30

tendonitis and tendon ruptures
pulmonary
peripheral nerve compression: carpal tunnel
rheumatoid nodules: strongly associated with positive RF

splenomegaly
pericarditis
vacultiis
eye involvement: scleritis, dry eyes, epi-scleritis: inflmm of thin membrane between the sclera and conjuctiva

Question 31

RA labs

Answer 31

supportive but not diagnostic

positive RF in 70-80% of pts
evelated CRP and ESR
mild anemia of chronic dz
high WBC count : 60% are neurtophils
synovial analysis: arthrocentesis shows fluid is cloudy, sterile, decreased viscosity, no crystals

Question 32

X ray findings RA

Answer 32

Soft tissue swelling
periarticualr osteopenia: bone loss near the joint
joint space narrowing
erosion
deformity

Question 33

RA diagnostic criteria

Answer 33

all of the following are present

inflmmatory arthritis in 3 or more joints
+RF and/or anti-CRP aka ACPA
elevated ESR or CRP
sx for longer than 6 weeks
excluding other causes

Question 34

dx for patients not meeting criterai

Answer 34

seronegative RA (lack both RF and ACPAS)
Based upon findings otherwise characteristic of RA if appropriate exclusions have been met
recent onset of ra
To avoid delays in initiation of treatment for pts with severe disease presentation

Question 35

increased mortality in RA

Answer 35

shortens life span by 5-10 years
cardiovascular complications
infections: 5x higher risk than general population
cancer and lymphoproliferative malgnancies : 5-8x higher risk of lymphoma

other clinical problems:
sjogren’s
osteoporosis
laryngeal manifestation
ossicles of the ear: tinnitus and decresead hearing

Question 36

RA management

Answer 36

early diagnosis and treatment necesary to prevent damge

no weight bearing exercising
poool therapy exercise

nsaids for sx releif
DMARDs: disease modifying anti-rheumatic drugs
assignment by rheumatoligst
methotrexate (MTX), gold, cyclosporin,immunran
hydrochloroquine : anti malaria drug, safer

Question 37

Felty syndrome

Answer 37

1-3% of RA
very high RF
RA in combination with splenomegaly, leukopenia, thrombocytopenia
HLA DR4+

usually occurs after many years of aggressive RA

pulmonary and skin infections common